From 1592c1abcf749ec197f7d8044dd2f985ca4b1d4b Mon Sep 17 00:00:00 2001 From: Dimitri Lozeve Date: Fri, 3 Jun 2022 19:16:16 +0200 Subject: [PATCH] Update post on HROs --- posts/high-reliability-organizations.org | 79 +++++++++++++++--------- 1 file changed, 49 insertions(+), 30 deletions(-) diff --git a/posts/high-reliability-organizations.org b/posts/high-reliability-organizations.org index 4c55e4f..42fd321 100644 --- a/posts/high-reliability-organizations.org +++ b/posts/high-reliability-organizations.org @@ -1,6 +1,6 @@ --- title: "High reliability organizations" -date: 2022-06-01 +date: 2022-06-03 tags: management, social science toc: false --- @@ -21,11 +21,14 @@ shuttles. They share several characteristics: an unforgiving environment, vast potential for error, and dramatic scales in the case of a failure. -[cite/t:@weick1999_organ] use the concept of "mindfulness", a kind of -"enriched awareness" (which I interpret as "awareness with explicit -processes"), consisting of the five elements listed below. This -mindfulness leads to the capacity to discover and manage unexpected -events, which in turn leads to reliability. +The paper identifies five processes common to HROs, that they group +into the concept of /mindfulness/ (a kind of "enriched +awareness"). Mindfulness is about allocating and conserving attention +of the group. It includes both being consciously aware of the +situation and /acting/ on this understanding. + +This mindfulness leads to the capacity to discover and manage +unexpected events, which in turn leads to reliability. * Characteristics of a high reliability organization @@ -33,38 +36,53 @@ An HRO is an organization with the following five attributes. ** Preoccupation with failure -There are many possible failures, most of them extremely -rare. Consequently, HROs study all forms of failure and near misses -with extreme carefulness and attention to detail. They also study the -/absence/ of failure: why it didn't fail, and the possibility that no -flaws were identified because we weren't attentive enough to potential -flaws. HROs encourage reporting all mistakes and anomalies by anyone. +Failures in HROs are extremely rare. To make it easier to learn from +them, the organization has to broaden the data set by expanding the +definition of failure and studying all types of anomalies and near +misses. Additionally, the analysis is much richer, and always +considers the reliability of the entire system, even for localized +failures. + +HROS also study the /absence/ of failure: why it didn't fail, and the +possibility that no flaws were identified because there wasn't enough +attention to potential flaws. + +To further increase the number of data point to study, HROs encourage +reporting all mistakes and anomalies by anyone. Contrary to most +organizations, members are rewarded for reporting potential failures, +even if their analysis is wrong or if they are responsible for +them. This creates an atmosphere of "psychological safety" essential +for transparency and honesty in anomaly reporting. ** Reluctance to simplify interpretations HROs avoid having a single interpretation for a given event. They encourage generating multiple, complex, contradicting interpretations -for every phenomenon. People are encouraged to have different views, -different backgrounds (important for [[id:cdfc701f-7b6e-40ec-be94-db64a74aef0d][Hiring]]), and are re-trained -often. To resolve the contradictions and the oppositions of views, -interpersonal and human skills are highly valued, possibly more than -technical skills. +for every phenomenon. These varied interpretations enlarge the number +of concurrent precautions. Redundancy is implemented not only via +duplication, but via skepticism of existing systems. + +People are encouraged to have different views, different backgrounds, +and are re-trained often. To resolve the contradictions and the +oppositions of views, interpersonal and human skills are highly +valued, possibly more than technical skills. ** Sensitivity to operations -HROs rely a lot on "situational awareness". Basically, we have to -check that there is no emergent phenomena (cf [[id:cabacd0d-2d40-450d-bbba-85c3539ff939][Complex systems]] and -[[id:65e2d955-ab29-432f-9f48-30605e3f688f][Compositionality]]): all outputs should always be explained by the known -inputs. Otherwise, there might be other forces at work that need to be -identified and dealt with. A small group of people may be dedicated to -this awareness at all times. +HROs rely a lot on "situational awareness". They are ensuring that no +[[https://en.wikipedia.org/wiki/Emergence][emergent phenomena]] emerge in the system: all outputs should always be +explained by the known inputs. Otherwise, there might be other forces +at work that need to be identified and dealt with. A small group of +people may be dedicated to this awareness at all times. ** Commitments to resilience HROs train people to be experts at combining all processes and events to improve their reactions and their improvisation skills. Everyone -should be an expert at managing surprise. This can include rapid -formation of ad hoc teams to improvise solutions to novel problems. +should be an expert at anticipating potential adverse events, and +managing surprise. When events get outside normal operational +boundaries, organizations members self-organize into small dedicated +teams to improvise solutions to novel problems. ** Underspecification of structures @@ -97,11 +115,12 @@ An interesting discussion is around the (alleged) trade-off between reliability and performance. It is assumed that HROs put the focus on reliability at the cost of throughput. As a consequence, it may not make sense for ordinary organizations to put as much emphasis on -safety and reliability, as it may cost money. +safety and reliability, as the cost to the business may be +prohibitive. However, investments in safety can also be viewed as investments in -learning. HROs view safety and reliability as a process of search and -learning (constant search for anomalies, learning the interactions +/learning/. HROs view safety and reliability as a process of search +and learning (constant search for anomalies, learning the interactions between the parts of a complex system, ensuring we can link outputs to known inputs). As such, investments in safety encourage collective knowledge production and dissemination. @@ -116,8 +135,8 @@ of the catastrophic consequences of any failure, but non-HROs can adopt the same practice to boost efficiency and learning to gain competitive advantage. -Additional lessons that can be learned from HROs (implicit in previous -discussion): +Additional lessons that can be learned from HROs (implicit in the +previous discussion): 1. The expectation of surprise is an organizational resource because it promotes real-time attentiveness and discovery. 2. Anomalous events should be treated as outcomes rather than